Complications in the Treatment of Infant Dysplasia

25 October, 2019 Aaron Boyles, DO Assistant Professor Children’s Hospital Colorado – Colorado Springs Colorado University School of Medicine

1 Disclosures None

2 Overview • Pavlik Harness • Closed reduction • Open reduction • Pelvic Pavlik Harness Complications Femoral Palsy  Occurs about 2.5% of the time  87% present in the first week

 Higher risk in older, larger patients with JBJS VOL. 93-A NUMBER 5 MARCH 2, 2011 more severe dysplasia  Strong predictor of treatment failure  97% success w/o FNP vs. 47% with FNP  Increased flexion has also been implicated1 1 Mubarak et al. JBJS VOL. 93-A NUMBER 5 MARCH 2, 2011 Femoral Nerve Palsy Treatment  Immediate removal of harness

 Watch closely for recovery

 Reapply harness once resolved

 Consider decreasing hip flexion

 Watch closely for recurrence

https://hipdysplasia.org/developmental-dysplasia-of-the-hip/child- treatment-methods/femoral-nerve-palsy/ Pavlik Harness Disease  Historic teaching: abandon Pavlik if unsuccessful after 2-4 weeks

 Based on Jones et al1 paper?

 >8 weeks in harness potentiated dysplasia  Recently this has been challenged

 Gornitzky et al2 showed no harm and improved α-angle in with average of 6 weeks in harness 1Jones et al J Pediatr Orthop. 1992 Nov-Dec;12(6):722-6. 2Gornitzky et al J Pediatr Orthop. 2018 Jul;38(6):297-304. Failure to Reduce in Pavlik  More failures in Ortolani positive hips

 Up to 40%1  Higher failure risk in Graf IV hips (inverted labrum, α-angle <43°)

 4.4 times higher risk of Pavlik failure2

1White, KK et al J Bone Joint Surg Am. 2010 Jan;92(1):113-20. 2Novias et al Clin Orthop Relat Res. 2016 Aug;474(8):1847-54. https://radiologyassistant.nl/pediatrics/developmental-dysplasia-of-the-hip- ultrasound Failure to Reduce in Pavlik: Treatment  Rigid abduction bracing has been shown to be an effective 2nd line treatment option

 Rigid abduction orthosis after Pavlik failure was reported to have 87% success rate1

 Hedequist showed 13 of 15 hips reduced in a semi-rigid abduction orthosis after Pavlik failure2

1Sankar et al J Bone Joint Surg Am. 2015 Feb 18;97(4):292-7. 2Hedequist et al J Pediatr Orthop. 2003 Mar-Apr;23(2):175-7. My Protocol  Start with Pavlik  Ultrasound and exam at 2 and 4 weeks  Exam for femoral nerve palsy  Transition to abduction orthosis if not stabilized in 4 weeks  Ultrasound and exam at 6 and 8 weeks  If no improvement at 8 weeks, abandon nonoperative treatment  Proceed with Closed vs Open reduction at ~6 months Closed & Open Reduction Complications Skin Breakdown  Spica casts have been reported to have skin complications up to 28% of the time1

 Waterproof, breathable cast liners have been shown to decrease skin excoriation due to soiling form 22% to 1.4%2

1DiFazio et al J Pediatr Orthop. 2011 Jan-Feb;31(1):17-22. 2Wolff et al J Pediatr Orthop. 1995 May-Jun;15(3):386-8. https://hipdysplasia.org/patient-stories/advocate- spotlight/spica-life/ Buchholz-Ogden Classification Avascular Necrosis  Incidence ranges widely 0-73%1

 Inconsistent classification and follow up

 Some forms of AVN do not appear until 9 years or older

1Roposch, A., Wedge, J.H. & Riedl, G. Clin Orthop Relat Res (2012) 470: 3499. Avascular Necrosis – Predictors Ossific Nucleus?  Segal et al showed that the ossific  A more recent meta-analysis showed nucleus is protective against AVN1 no protective benefit3

 This finding has since been  Prospective level 2 study showed challenged by multiple authors AVN rates were unaffected by the

 One meta-analysis showed a ossific nucleus or age4 protective affect for more severe forms of AVN2 1Segal et al J Pediatr Orthop. 1999 Mar-Apr;19(2):177-84. 2Roposch et al J Bone Joint Surg Am. 2009 Apr;91(4):911-8.

3 Chen et al J Bone Joint Surg Am. 2017 May 3;99(9):760-767. 4Sankar et al J Pediatr Orthop. 2019 Mar;39(3):111-118. Avascular Necrosis – Predictors Abduction in cast  Higher degrees of abduction have been associated with AVN

 Schur et al showed increase AVN rates in patients <6 months when abduction was >50°

 Jaramillo et at showed a correlation between increased abduction and decreased perfusion on MRI. Avascular Necrosis – The Utility of Perfusion MRI  Gadolinium contrast MRI can show decreased femoral head and epiphyseal perfusion after spica casting1,2

 This decrease has been linked to the development of AVN 1,2,3

 MRI can guide treatment and may 1Jaramillo et at AJR 1998;170:1633-1637 2Tiderius et al J Pediatr Orthop 2009;29:14Y20 decrease the incidence of AVN4 3Haruno et al Journal of Pediatric Orthopaedics B 2019, 28:424–429 4Gornitzky et al Clin Orthop Relat Res (2016) 474:1153–1165 Avascular Necrosis Treatment  Address resultant deformity Schneidmueller et at J Pediatr Orthop 2006;26:486Y490

 Trochanteric overgrowth

 Greater trochanter epiphysiodesis

 Greater trochanteric advancement

 Relative femoral neck lengthening  Femoral head deformity

 Osteochondroplasty

 Femoral head reduction Avascular Necrosis Treatment  Coxa valga

 Varus osteotomy

 Guided Growth  Address any LLD

 Contralateral epiphyseodesis

Oh et al CORR 2005 Number 434, pp. Torode et al J Child Orthop (2015) 86–91 9:371–379 Re-dislocation  Re-dislocation can happen after both  Higher risk of re-dislocation after closed and open reduction open reduction when:

 Sankar et al reported 9% re-  Right hip  Bilateral dislocation after closed reduction1  Less abduction in cast 39° vs 51° and 5.9% after open redution2

1Sankar et al J Pediatr Orthop 2019;39:111–118 2Sanker et al J Pediatr Orthop 2011;31:232–239 Re-dislocation  Failure of open reduction can also occur secondary to technical error

 2 studies cite incomplete release of inferomedial capsular contracture and the transverse acetabular ligament as reasons for failure1,2

1Kershaw et al J Bone Joint Surg Br. 1993;75B:744–749. 2McCluskey et al J Pediatr Orthop. 1989;9:633–639. Schwend, RM 2011 Anterior Approach for Open Reduction of the Developmentally Dislocated Hip in Flynn, JM, Wiesel, SW (Ed.) Operative Techniques in Pediatric Orthopedics p. 473 Persistent Dysplasia - Predictors  Initial IHDI classification has been shown to be predictive of need for future pelvic osteotomy after successful closed reduction

Ramo et al J Pediatr Orthop 2018;38:16–21 Persistent Dysplasia - Treatment  Pelvic osteotomy  Salter, Pemberton, San Diego, Dega, Triple  Indication  Persistent elevation in acetabular index  Shin at al suggest that the Center Edge Angle and Acetabular Index at age 3 can be used as a guideline  Patients with AI ≥32° and/or CEA ≤14° were more likely to have a satisfactory outcome if osteotomy was performed Shin et al J Bone Joint Surg Am. 2016;98:952-7 Pelvic Osteotomy Complications Avascular Necrosis  Higher rate with excessive inferior displacement of the proximal femur after Pemberton1

1Wu et al J Bone Joint Surg Am. 2010;92:2083-94 Femoroacetabular Impingement  Castaneda et al reported that radiographic FAI occurred 12% of the time after innominate osteotomy

 1 in 10 had clinically significant FAI

 A correction of the AI of more than 20° was a risk factor for developing FAI Summary  Start with Pavlik  Open reduction

 Monitor for femoral nerve palsy  Release inferomedial capsule and TAL  Consider abduction orthosis  Amount of abduction in cast is still important  Attempt brace treatment up to 8 weeks or longer if progress is seen on US  AVN  Closed reduction  Monitor long term, may not appear until 9 year or older  Use waterproof, breathable cast liner

 Limit abduction in cast to <50°  Beware of IHDI 3 and 4 hips

 Don’t wait for the ossific nucleus  Higher rate of failed closed reduction

 Perfusion MRI?  Higher rate of later pelvic osteotomy Summary  Monitor for acetabular remodeling

 Acetabular index > 32 at age 3 should prompt osteotomy

 Failure to progress by age 6  Pelvic osteotomy considerations

 Walk the line between instability and impingement

 Overcorrection can lead to AVN and FAI Questions?

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